“If you didn’t document it, it didn’t happen.”

While I sat in the courtroom over the last week listening to a Plaintiff’s attorney chide me for everything from failure to document and time every single time I went into a patient’s room for a follow-up exam to failing to diagnose a condition that even his expert witness had to look up (and who only found one similar case report), I thought back to the “Malpractice Ball” traditionally held every year by the Marquette Medical, Law and Dental Schools.  It’s a mixer to help bring the students from the different disciplines together in the hopes of forming friendships, making contacts, and encouraging them to play nice if only for an evening.  Too bad we all had to grow up and become like predator and prey;  a fox and a hound who though similar are enemies due to circumstance.

If there’s one thing I learned from this whole legal experience – it’s to treat every document I touch as though someone else  five years from now will be looking at it.  Just like the lab books we kept in organic chemistry, that Someone Else should be able to accurately follow our thinking and be able to draw the same conclusions.  They should be able to concede that given those circumstances, they would have gotten the exact same results.

I asked my lawyer what common lawsuits are brought up against Emergency Physicians.  He told me that missed diagnoses by far surpass any other suit.  He said the suits that are successfully won by the physician are the ones in which it’s clearly documented that the physician ordered the appropriate tests and arranged for the proper continued medical care.  He also noted that sometimes families will sue because they have questions about what led to a patient’s situation and just want to know what happened.  He states that many times physicians don’t take the time to discuss a lab result, a diagnosis, a patient condition.  A few extra moments can save a lot of people a lot of time and money.

Now that I have spent my time being grilled both under direct and cross-examination, I can tell you that I never again want to go through the feeling of having my character, my medical decision-making, my very honesty brought into question and exposed for everyone to see.  While a fellow doctor understands that you don’t automatically write down every aspect of a patient encounter, when it’s questioned whether something really happened or not based on a gap in the record, you have to wonder if the store clerk sitting on the jury panel really gets it.  We don’t write everything down.  If my physical exam hasn’t changed from the prior hour’s physical exam, I’m not going to note it… although now I am considering it.  I wonder how much one of those helmet cams costs…?